Critérios brasileiros de elegibilidade à doação de sangue para pacientes dermatológicos

A focused and commented review on the impact of dermatologic diseases and interventions in the solidary act of donating blood is presented to dermatologists to better advise their patients. This is a review of current Brazilian technical regulations on hemotherapeutic procedures as determined by Ministerial Directive #1353/2011 by the Ministry of Health and current internal regulations of the Hemotherapy Center of Ribeirão Preto, a regional reference center in hemotherapeutic procedures. Criteria for permanent inaptitude: autoimmune diseases (>1 organ involved), personal history of cancer other than basal cell carcinoma, severe atopic dermatitis or psoriasis, pemphigus foliaceus, porphyrias, filariasis, leprosy, extra pulmonary tuberculosis or paracoccidioidomycosis, and previous use of etretinate. Drugs that impose temporary ineligibility: other systemic retinoids, systemic corticosteroids, 5-alpha-reductase inhibitors, vaccines, methotrexate, beta-blockers, minoxidil, anti-epileptic, and anti-psychotic drugs. Other conditions that impose temporary ineligibility: occupational accident with biologic material, piercing, tattoo, sexually transmitted diseases, herpes, and bacterial infections, among others. Discussion: Thalidomide is currently missing in the teratogenic drugs list. Although finasteride was previously considered a drug that imposed permanent inaptitude, according to its short halflife current restriction of 1 month is still too long. Dermatologists should be able to advise their patients about proper timing to donate blood, and discuss the impact of drug withdrawal on treatment outcomes and to respect the designated washout periods

Intrahepatic Cholestasis in Sickle Cell Disease: A Case Report

Intrahepatic cholestasis (SCIC) is an uncommon but potentially fatal complication of sickle cell disease (SCD), with a high death rate, observed mainly in patients with homozygous sickle cell anemia. Herein, we describe a case of severe SCIC treated successfully with aggressive manual exchange transfusion (ET). The patient was admitted with enlarged liver and signs of hepatic failure, such as hyperbilirubinemia and coagulopathy. There was no evidence of viral hepatitis or biliary obstruction. We performed several sessions of ET in order to reduce the percentage of HbS to levels inferior to 30%, which was successfully accomplished. The patient had a complete recovery of hepatic function. This case has shown that ET is an effective treatment of SCIC and should be introduced early on the onset of this severe complication

Automated erythrocytapheresis in sickle cell disease: strategies for reducing red blood cell consumption and exposure to different blood donors

A transfusão de concentrado de hemácias (CH) representa a principal terapia no manejo das complicações da doença falciforme, aumenta a massa eritrocitária circulante, melhora a perfusão tecidual, interrompe o ciclo patológico vasoclusivo-hemolítico e suprime a hematopoese. Sobrecarga de ferro, aloimunização, doenças transmissíveis pelo sangue e hiperviscosidade são os eventos adversos que moderam o seu uso. A transfusão de troca manual reduz a sobrecarga de ferro e evita a hiperviscosidade, mas aumenta o consumo de hemácias. A transfusão de troca automatizada (RBCX) é mais eficaz que a manual no controle da concentração da hemoglobina S (HbS) e na profilaxia da sobrecarga de ferro, mas amplifica esse consumo. Suas principais limitações decorrem do incremento dos riscos associados à elevada exposição a diferentes doadores: a aloimunização e as doenças infecciosas. Visando reduzi-los, adotamos o uso de concentrado de hemácias (CH) duplas, obtidos por aférese, de doadores de repetição vinculados aos receptores, associados a duas modalidades distintas de trocas automatizadas, a depleção isovolêmica (DI) seguida de transfusão, duas fases (2P), e a DI e troca isovolêmica seguidas de transfusão, três fases (3P). Analisamos retrospectivamente os resultados Comparamos o consumo de hemácias entre cada troca realizada em 2P ou 3P com uma troca automatizada de uma única fase (1P) simulada no sistema de aférese Spectra Optia, partindo das mesmas condições iniciais para os mesmos resultados finais de hematócrito (Ht) e concentração de HbS. Verificamos a exposição a diferentes doadores obtida pela adoção dessas estratégias combinadas e estimamos sua redução. Resultados: 20 pessoas tiveram 197 sessões incluídas no estudo, sendo 98 (2P) e 99 (3P). Consumo de hemácias, medianas, mL: 1P vs 2P (474 vs 344) e 1P vs 3P (1076 vs 692), ambas com p<0,0001. Em relação à 1P, este consumo foi reduzido em 28,2% e 33,5%, mediana e média, respectivamente, para 2P e 3P. HbS, %: pré-2P 41,6% (20,5 a 69,5); pós-2P 24,7% (13,1 a 45,4), pré-3P 44,8% (±11,3) e pós-3P 17,1% (±6,3). Ht, %: pré-2P 28,6% (25,5 a 35,4), pós-2P 28,2 (23,3 a 31,7), pré-3P 29,3% (23,2 a 34,3) e pós- 3P 29,6% (26,2 a 33,6). No total, foram consumidos 600 CH de 333 doações de 155 diferentes doadores. Médias de consumo de CH por procedimentos: 2,0 U (2P) e 4,1 U (3P). Média da exposição a doações e doadores por procedimento: 1,1 (2P) e 2,3 (3P). A redução da exposição potencial a diferentes doadores foi de 74,2%. Eventos adversos: 8/197 (4%) procedimentos, em 3/20 (15%) pacientes, sem gravidade, nenhuma nova aloimunização ou evidência clínica de novo acidente vascular cerebral. Depleção plaquetária, %: 2P 20,6% (- 53,8 a 44,2) e 3P 49,2 (-14,5 a 70,1). Ausência de contagem de plaquetas pós-aférese inferior a 100 x 103/?L. Em relação à técnica de 1P, as técnicas em 2P e em 3P proporcionaram redução extremamente significante do consumo de hemácias e foram bem toleradas. A utilização de CH dupla de doadores de repetição vinculados reduziu drasticamente a exposição a diferentes doadores e foi viável a longo prazo, o que pode contribuir para ampliar as indicações de RBCXTransfusion of red blood cell concentrates (RBCC) is the main therapy in the management of sickle cell disease complications; it increases circulating erythrocyte mass, improves tissue perfusion, interrupts the vaso-occlusive-hemolytic pathological cycle, and suppresses hematopoiesis. Iron overload, alloimunization, blood-transmitted diseases, and hyperviscosity are adverse events that moderate its use. Manual exchange transfusion reduces iron overload and prevents hyperviscosity, but increases the consumption of red blood cells. Automated exchange transfusion (RBCX) is more effective than manual exchange in the control of hemoglobin S (HbS) and in the prophylaxis of iron overload, but it amplifies this consumption. Its major limitations result from the increase of high donor exposure associated risks: alloimunization and transfusion-transmitted diseases. Aiming to reduce them, we have adopted the use of double RBCC, obtained by apheresis from repetition donors linked to recipients, associated with two distinct modalities of automated exchanges, isovolemic depletion (ID) followed by transfusion, two phases (2P), and ID and isovolemic exchange followed by transfusion, three phases (3P). We analyzed the results retrospectively and compared the consumption of red blood cells between every exchange conducted in two or three phases with an one-phase (1P) automated exchange, simulated in the Spectra Optia apheresis system, leaving from the same initial conditions to the same final results of hematocrit (Ht) and HbS concentration. We verified the exposure to different donors obtained by the adoption of these combined strategies and estimated its reduction. Results: 20 individuals had 197 sessions included in this study, 98 (2P) and 99 (3P). Red blood cell (RBC) consumption, median, mL: 1P vs 2P (474 vs 344) and 1P vs 3P (1076 vs 692), both with p<0.0001. In relation to the exchange of 1P, the consumption of RBC cells was reduced in 28.2% and 33.5% (p<0.0001), respectively, median and mean, for exchanges in 2P and 3P. HbS,%: pre-2P 41.6% (20.5 to 69.5), post-2P 24.7% (13.1 to 45.4), pre-3P 44.8% (±11.3) and post-3P 17.1% (±6.3). Ht,%: pre-2P 28.6 (25.5 to 35.4), post-2P 28.2 (23.3 to 31.7), pre-3P 29.3% (23.2 to 34.3) and post-3P 29.6 (26.2 to 33.6). In total, 600 RBCC were consumed out of 333 donations from 155 different donors. Means of RBCC consumption by procedures: 2.0 U (2P) and 4.1 U (3P). Mean of the exposure to donations and donors by procedure: 1.1 (2P) and 2.3 (3P). The reduction of potential exposure to different donors was 74.2%. Adverse events: 8/197 (4%) procedures, in 3/20 (15%) patients, no severity, no new alloimunization or clinical evidence of new cerebrovascular accident. Platelet depletion,%: 2P 20.6% (-53.8 to 44.2) and 3P 49.2% (-14.5 to 70.1). Absence of post-apheresis platelet count lower to 100 x 103/?L. Regarding phase 1 technique, the techniques in 2 or 3 phases enabled extremely significant reduction of RBC consumption and were well tolerated. The use of double RBCC from linked repetition donors reduced drastically exposure to donors and was feasible in the long term, what might contribute to expand RBCX indication

Automated erythrocytapheresis in sickle cell disease: strategies for reducing red blood cell consumption and exposure to different blood donors

A transfusão de concentrado de hemácias (CH) representa a principal terapia no manejo das complicações da doença falciforme, aumenta a massa eritrocitária circulante, melhora a perfusão tecidual, interrompe o ciclo patológico vasoclusivo-hemolítico e suprime a hematopoese. Sobrecarga de ferro, aloimunização, doenças transmissíveis pelo sangue e hiperviscosidade são os eventos adversos que moderam o seu uso. A transfusão de troca manual reduz a sobrecarga de ferro e evita a hiperviscosidade, mas aumenta o consumo de hemácias. A transfusão de troca automatizada (RBCX) é mais eficaz que a manual no controle da concentração da hemoglobina S (HbS) e na profilaxia da sobrecarga de ferro, mas amplifica esse consumo. Suas principais limitações decorrem do incremento dos riscos associados à elevada exposição a diferentes doadores: a aloimunização e as doenças infecciosas. Visando reduzi-los, adotamos o uso de concentrado de hemácias (CH) duplas, obtidos por aférese, de doadores de repetição vinculados aos receptores, associados a duas modalidades distintas de trocas automatizadas, a depleção isovolêmica (DI) seguida de transfusão, duas fases (2P), e a DI e troca isovolêmica seguidas de transfusão, três fases (3P). Analisamos retrospectivamente os resultados Comparamos o consumo de hemácias entre cada troca realizada em 2P ou 3P com uma troca automatizada de uma única fase (1P) simulada no sistema de aférese Spectra Optia, partindo das mesmas condições iniciais para os mesmos resultados finais de hematócrito (Ht) e concentração de HbS. Verificamos a exposição a diferentes doadores obtida pela adoção dessas estratégias combinadas e estimamos sua redução. Resultados: 20 pessoas tiveram 197 sessões incluídas no estudo, sendo 98 (2P) e 99 (3P). Consumo de hemácias, medianas, mL: 1P vs 2P (474 vs 344) e 1P vs 3P (1076 vs 692), ambas com p<0,0001. Em relação à 1P, este consumo foi reduzido em 28,2% e 33,5%, mediana e média, respectivamente, para 2P e 3P. HbS, %: pré-2P 41,6% (20,5 a 69,5); pós-2P 24,7% (13,1 a 45,4), pré-3P 44,8% (±11,3) e pós-3P 17,1% (±6,3). Ht, %: pré-2P 28,6% (25,5 a 35,4), pós-2P 28,2 (23,3 a 31,7), pré-3P 29,3% (23,2 a 34,3) e pós- 3P 29,6% (26,2 a 33,6). No total, foram consumidos 600 CH de 333 doações de 155 diferentes doadores. Médias de consumo de CH por procedimentos: 2,0 U (2P) e 4,1 U (3P). Média da exposição a doações e doadores por procedimento: 1,1 (2P) e 2,3 (3P). A redução da exposição potencial a diferentes doadores foi de 74,2%. Eventos adversos: 8/197 (4%) procedimentos, em 3/20 (15%) pacientes, sem gravidade, nenhuma nova aloimunização ou evidência clínica de novo acidente vascular cerebral. Depleção plaquetária, %: 2P 20,6% (- 53,8 a 44,2) e 3P 49,2 (-14,5 a 70,1). Ausência de contagem de plaquetas pós-aférese inferior a 100 x 103/?L. Em relação à técnica de 1P, as técnicas em 2P e em 3P proporcionaram redução extremamente significante do consumo de hemácias e foram bem toleradas. A utilização de CH dupla de doadores de repetição vinculados reduziu drasticamente a exposição a diferentes doadores e foi viável a longo prazo, o que pode contribuir para ampliar as indicações de RBCXTransfusion of red blood cell concentrates (RBCC) is the main therapy in the management of sickle cell disease complications; it increases circulating erythrocyte mass, improves tissue perfusion, interrupts the vaso-occlusive-hemolytic pathological cycle, and suppresses hematopoiesis. Iron overload, alloimunization, blood-transmitted diseases, and hyperviscosity are adverse events that moderate its use. Manual exchange transfusion reduces iron overload and prevents hyperviscosity, but increases the consumption of red blood cells. Automated exchange transfusion (RBCX) is more effective than manual exchange in the control of hemoglobin S (HbS) and in the prophylaxis of iron overload, but it amplifies this consumption. Its major limitations result from the increase of high donor exposure associated risks: alloimunization and transfusion-transmitted diseases. Aiming to reduce them, we have adopted the use of double RBCC, obtained by apheresis from repetition donors linked to recipients, associated with two distinct modalities of automated exchanges, isovolemic depletion (ID) followed by transfusion, two phases (2P), and ID and isovolemic exchange followed by transfusion, three phases (3P). We analyzed the results retrospectively and compared the consumption of red blood cells between every exchange conducted in two or three phases with an one-phase (1P) automated exchange, simulated in the Spectra Optia apheresis system, leaving from the same initial conditions to the same final results of hematocrit (Ht) and HbS concentration. We verified the exposure to different donors obtained by the adoption of these combined strategies and estimated its reduction. Results: 20 individuals had 197 sessions included in this study, 98 (2P) and 99 (3P). Red blood cell (RBC) consumption, median, mL: 1P vs 2P (474 vs 344) and 1P vs 3P (1076 vs 692), both with p<0.0001. In relation to the exchange of 1P, the consumption of RBC cells was reduced in 28.2% and 33.5% (p<0.0001), respectively, median and mean, for exchanges in 2P and 3P. HbS,%: pre-2P 41.6% (20.5 to 69.5), post-2P 24.7% (13.1 to 45.4), pre-3P 44.8% (±11.3) and post-3P 17.1% (±6.3). Ht,%: pre-2P 28.6 (25.5 to 35.4), post-2P 28.2 (23.3 to 31.7), pre-3P 29.3% (23.2 to 34.3) and post-3P 29.6 (26.2 to 33.6). In total, 600 RBCC were consumed out of 333 donations from 155 different donors. Means of RBCC consumption by procedures: 2.0 U (2P) and 4.1 U (3P). Mean of the exposure to donations and donors by procedure: 1.1 (2P) and 2.3 (3P). The reduction of potential exposure to different donors was 74.2%. Adverse events: 8/197 (4%) procedures, in 3/20 (15%) patients, no severity, no new alloimunization or clinical evidence of new cerebrovascular accident. Platelet depletion,%: 2P 20.6% (-53.8 to 44.2) and 3P 49.2% (-14.5 to 70.1). Absence of post-apheresis platelet count lower to 100 x 103/?L. Regarding phase 1 technique, the techniques in 2 or 3 phases enabled extremely significant reduction of RBC consumption and were well tolerated. The use of double RBCC from linked repetition donors reduced drastically exposure to donors and was feasible in the long term, what might contribute to expand RBCX indication

The Praktikós and the Gn&omacr;stikós of Evagrius of Pontus: study, translation and commentaries

Há, neste estudo, junto de alguns ensaios e comentários, uma tradução de dois tratados de ascese atribuídos a Evágrio Pôntico (345-399 d.C.): o Praktikós e o Gn&omacr;stikós. Dada a má sorte da transmissão de seus manuscritos desde a sua condenação no II Concílio de Constantinopla (553 d.C.), tem havido, através dos séculos, muitas dificuldades relacionadas aos estudos evagrianos. Com efeito, não há apenas o problema da atribuição equivocada de suas obras a outros autores - por exemplo, as atribuições de algumas delas a Nilo de Ancira, um recurso filológico que foi, provavelmente, um meio de evitar a suposta censura -, mas também o de muitas concepções equivocadas acerca de suas ideias. Para nos atentarmos a isso, foi necessário analisar, ao menos de passagem, a transmissão de seus manuscritos, o que nos foi possível apenas por meio da discussão do estudo filológico já realizado por Antoine e Claire Guillaumont, ou seja, indiretamente. Com efeito, esse problema filológico parece trespassar todo o conteúdo literário e filosófico de Evágrio a ser estudado. De qualquer modo, Evágrio, como uma figura histórica, pode ser conhecido não apenas por meio de descrições feitas nos seus próprios manuscritos, mas também por aquelas que se fazem presentes em manuscritos de outros autores da Antiguidade Tardia, como Sócrates Escolástico, Paládio e Rufino de Aquileia em suas obras historiográficas. Além do mais, existem, em outras fontes, representações de Evágrio que também são interessantes, como as epistulae de Jerônimo. Conforme será visto neste trabalho, é importante estar atento a isto: Evágrio não era indiferente à ciência de seu tempo. Ao incorporar as principais discussões do período tardo-antigo no seu pensamento, ele escreveu com estilo próprio acerca da alma humana, do corpo humano e do universo. É possível que ele tenha sido o primeiro autor cristão a expressar seus pensamentos em kephálaia - algo como capítulos muito curtos. E, por último mas não menos importante, o pensamento médico que se faz presente em sua obra e a importância da linguagem alegórica como instrumento de composição e hermenêutica são elementos que o fazem simultaneamente um autor original e um homem do seu próprio tempo.In this study, there is, along with some essays and commentaries, a translation of two ascetical treatises attributed to Evagrius of Pontus (345-399 C.E.): the Praktikós and the Gn&omacr;stikós. Given the misfortune of the transmission of his manuscripts since his condemnation in the Second Council of Constantinople (553 C.E.), there have been, throughout the centuries, many hindrances related to Evagrian studies. In effect, there is not only the problem of the misattributions of his works to other authors - for example, the attributions of some of these works to Nile of Ancyra, a philological tool that is likely to have been a way of getting rid of the so-called censorship -, but also many misconceptions about his ideas. To be aware of this, it was necessary to analyze, at least in passing, the transmission of his manuscripts, which was possible for us only through discussing the philological study already made by Antoine and Claire Guillaumont, i.e., indirectly. After all, this philological problem seems to go through all the Evagrian literary and philosophical content to be studied here. At any rate, Evagrius, as a historical person, can be known not only through the depictions made in his own manuscripts, but also through those present in the manuscripts of other late-antique authors, such as Socrates Scholasticus, Palladius and Rufinus of Aquileia in their historiographic oeuvre. Furthermore, there are also interesting depictions of Evagrius in other sources, such as the epistulae of Jerome. As will be seen in this research, it is also important to pay attention to this: Evagrius was not indifferent to the science of his time. By incorporating the main late-antique discussions in his thinking, he wrote about the human soul, the human body and the universe in a unique style. He is said to have been the first Christian writer to express his thoughts in kephálaia - something like very small chapters. And, last but not least, the medical thinking present in his work and the importance of the allegorical language as a tool of composition and hermeneutics are elements that make him simultaneously an original thinker and a man of his own time

Therapeutic Leukapheresis in Patients with Leukostasis Secondary to Acute Myelogenous Leukemia

Leukostasis is a relatively uncommon but potentially catastrophic complication of acute myelogenous leukemia (AML). Prompt leukoreduction is considered imperative to reduce the high mortality rate in this condition. Leukapheresis, usually associated with chemotherapy, is an established approach to diminish blast cell counts. We report a single center experience in managing leukostasis with leukapheresis. Fifteen patients with leukostasis of 187 patients with AML (8.02%) followed at our institution were treated with leukapheresis associated with chemotherapy. The procedures were scheduled to be performed on a daily basis until clinical improvement was achieved and WBC counts were significantly reduced. Overall and early mortalities, defined as that occurred in the first 7 days from diagnosis, were reported. A high proportion of our patients with leukostasis (46.66%) had a monocytic subtype AML (M4/M5, according to French-American-British classification). The median overall survival was 10 days, despite a significant WBC reduction after the first apheresis procedure (from 200.7 X 10(9)/L to 150.3 X 10(9)/L). Almost half of patients (7/15) had an early death. Therapeutic leukapheresis, associated or not to chemotherapy, is an effective approach to reduce WBC counts in patients with AML and leukostasis; however, this therapeutic procedure does not appear to change significantly the sombre prognosis observed in the majority of patients with this complication. Other forms of treatment must be found to reduce the high mortality rate related to leukostasis. J. Clin. Apheresis 26:181-185, 2011. (C) 2011 Wiley-Liss, Inc.Centro Regional de Hemoterapia de Ribeirao PretoUniversidade de São Paulo - Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto FMRP-USPUniversidade de Sao Paulo-USP, Ribeirao Preto, Sao Paulo, Brazil[306/2008